Closure of mitral and tricuspid valve
Loudest at apex
Closure of aortic/pulmonic
S1 split- causes
Delayed RV activaiton
Increased/decreased S1 intensity
Increased: short PR interval, mitral stenosis, tachycardia
Decreased: long PR interval, mitral regurg, severe mitral stenosis, stiff LV
What is physiological splitting?
Occurs with S2 upon inspiration due to delay of pulmonic valve closure bc more blood--> lungs
What can cause widened splitting of S2?
RBBB, pulmonic stenosis
Fixed splitting of S2
doesn't vary with resp = atrial septal defect
Paradoxical splitting of S2
Reverse pattern with resp
Due to LBBB, advanced aortic stenosis
What are examples of extra heart sounds?
S3 or S4 gallop
What causes an ejection click?
Abnormal valves --> abnormal valve closure or opening sounds
If heard after S1, it's when the aortic or pulmonic valve are abnormal (i.e. bicuspid aortic) or dialted
What causes a mid or late systolic click?
Due to systolic prolapse of mitral or tricuspid valve
What causes an opening snap?
A thickened mitral or tricuspid valve: high pitched, best heard between apex & left sternal border
What causes an S4 gallop?
End-diastolic sound (right before S1) that's generated by L or R atrium contracting against a stiffened ventricle
Best heard at apex or LLSB-- dull, low pitched sound
Usually indicates cardiac disease, may be normal in individuals over age 50 due to aging/stiffening of LV
What causes an S3 gallop?
Early diastolic sound that corresponds to early ventricular filling
Dull, low pitched, best heard with bell at the apex or LLSB
Normal in children/young adults
Indicates heart failure in adults
Note that opening snap and S3 are both early diastolic sounds but opening snap is high pitched & heard btw apex & LLSB whereas S3 is low pitched at heard at apex/LLSB
What causes a murmur?
Turbulent blood flow. Mechanisms:
1. Flow across a partial obstruction (stenotic valve)
2. Increased flow through normal structures (high output
states such as anemia or pregnancy)
3. Ejection into a dilated chamber (dilated aortic root)
4. Regurgitant flow across an incompetent valve
5. Abnormal shunting of blood from one vascular
chamber to a lower-pressure chamber (ventricular
septal defect, patent ductus).
What are the 3 main types of systolic murmurs:
What causes a systolic ejection murmur?
**severity is greater if the peak of murmur is later
What causes a pansystolic/holosystolic murmur?
Mitral regurg, Tricuspid regurg, VSD
What causes late systolic murmurs?
Mitral valve prolapse
What causes diastolic murmurs?
Early decrescendo: regurgitant flow through aortic/pulmonic valve
Mid-to-late: turbulent flow through stenotic mitral/tricuspid valve or increaed flow accross a normal valve
*if it's stenosis, preceded by opening snap
Prolonged mid-to-late: severe mitral or tricuspid stenosis
Continuous: patent ductus arteriosus
To-and-fro: aortic/pulmonic stenosis & regurgitaiton
Locations of murmurs
Which heart sounds do you hear for the valvular diseases?
Aortic stenosis: S4, Harsh systolic ejection murmur, paradoxical splitting (Also: delayed carotid, reduced A2)
Aortic regurg: wide pulse pressure, blowing decrescendo diastolic murmur LLSB, low frequency diastolic rumble=Austin flint, displaced hyperdynamic LV impulse
Mitral stenosis: Increased S1, opening snap in early diastole, diastolic rumble with presystolic accentuation =murmur , signs of pulm htn (RV heave, increased P2)
Mitral regurg: holosystolic murmur at apex that worsens with fist clench, S3